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WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232 (209)468-3420 <br /> NON-REFUNDABLE PERMIT WViW.S Ov.OY /ehd EXPIRES 1 YEARFROMDATE ISSUED <br /> JOB ADDRESS CITY/ZIPlytm� 64-7 60L m <br /> r 2 <br /> CROSS STREET i'�,1 u h-t APN 0 PARCEL SIZE l LAND USE APPLICATION# o <br /> 1 �� <br /> OWNER NAME J b q� PHONEQ� ���� Cl) <br /> ly y ?`J� <br /> OWNER ADDRESS M, (,4CITY/STATE/ZIP <br /> CONTRACTOR PHONE Moo L?w /�(� [—) � <br /> CONTRACTOR ADDRESS Ez( CITY/STATE/ZIP! ' (A <br /> SUBCONTRACTOR/CONSULTANT / �� PHONE _4Z& <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITY/STATE/ZIP <br /> LICENSE �C-57 El C-61 ❑ D-09 ❑ Other NUMBER 4W6a- EXPIRATION DATE /� <br /> BILLING PARTY: ❑OWNER ❑CONTRACTOR ❑ SUBCONTRACTOR/CONSULTANT <br /> DOMESTIC WELL SAMPLING: ❑ General Mineral/Coliform Bacteria (4391) Cl Dibromochloropropane(4392)❑ Arsenic(4393) <br /> INTENDED USE ❑ Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK ❑ New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings ❑ Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ew Pum Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method ❑ Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well Depth ft Excavation in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Conductor Casing in diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_ in Thickness/Gauge/ASTM Sched ❑ Steel ❑ Plastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depth ft ❑ Neat Cement(94 lb bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Bentonite(20%solids) ❑ Other <br /> Grout Placement Method ❑ Pumped ❑ Free Fall ❑ Other ❑ Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller ❑ Pump Contractor ❑ Other <br /> ❑ Concrete Pedestal❑Dimensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORK S COMPENSATION LAWS. <br /> I M2TiM= <br /> EREQUIRED F R INSP CTIONS -PLEASE CALL (209), 95.3-7697 <br /> SIGNE TITLE DATE <br /> RECEAM <br /> A116 I <br /> J. HE kL H E R M N <br /> D PARTMENTT� USE O LY <br /> Application Accepted By v Date Area / / Employee ID# <br /> Grout Inspection By Date ❑ SPECIAL Well Permit <br /> r <br /> Pump Inspection By �fcg\t' '® Date hof l lam+ ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth ft <br /> COMMENTS <br /> PE SC Received Check#/ Amount at Permit/ Invoice# Well ID# <br /> Codes Info B Cash Remitted Service Request# <br /> EHD 43-06 6/11/2019 WELL/PUMP PERMIT <br />